Downloaded from http://bmjopen.bmj.com/ on January 12, 2018 - Published by group.bmj.com Open Access Research Clinical value of chest pain presentation and prodromes on the assessment of cardiovascular disease: a cohort study John Robson, 1 Luis Ayerbe, 1 Rohini Mathur, 1 Juliet Addo, 2 Andrew Wragg 3 To cite: Robson J, Ayerbe L, ABSTRACT Strengths and limitations of this study Mathur R, et al . Clinical value Objectives: The recognition of coronary artery of chest pain presentation disease (CAD) among patients who report chest pain ▪ Chest pain of all clinical presentations (specified, and prodromes on the remains difficult in primary care. This study unspecified and musculoskeletal) is associated assessment of cardiovascular investigates the association between chest pain with an increased risk of acute coronary artery disease: a cohort study. BMJ (specified, unspecified or musculoskeletal) and disease (CAD) and increased longer term cardio- Open 2015; 5 :e007251. prodromes (dyspepsia, fatigue or dyspnoea), with first- doi:10.1136/bmjopen-2014- vascular (CV) risk. ever acute CAD, and increased longer term 007251 ▪ Dyspepsia and dyspnoea in patients with chest cardiovascular risk. pain are associated with acute CAD and longer Design: Cohort study. term CV risk. Fatigue is also associated with ▸ Prepublication history and Setting: Anonymised clinical data recorded increased risk of CAD. additional material is available. To view please visit electronically by general practitioners from 140 primary ▪ The data analysed in this study are derived from an the journal (http://dx.doi.org/ care surgeries in London (UK) between April 2008 and almost complete population and not selected indivi- 10.1136/bmjopen-2014- April 2013. duals or organisations; therefore, they provide the 007251). Participants: Data were extracted for all patients aged least biased sample frame and are likely to be repre- sentative of similar ethnically diverse populations. 30 years and over at the beginning of the study period, Received 19 November 2014 ▪ It was also possible to analyse several variables registered in the surgeries. Revised 19 January 2015 simultaneously, allowing the effect of multiple Main outcome measures: Clinical data included Accepted 1 February 2015 symptoms to be assessed. chest pain, dyspepsia, dyspnoea and fatigue, first-ever ▪ It is possible that this study underestimates the CAD and long-term cardiovascular risk (QRisk2). incidence of CAD as death outside the hospital Regression models were used to analyse the may not always be recorded in the general practi- association between chest pain together with tioners ’ records. Patients who reported chest pain prodromes and CAD and QRisk2 ≥ 20%. were more likely to have QRisk2 estimations; Results: 354 052 patients were included in the study. therefore, the association between the symptoms 4842 patients had first-ever CAD of which 270 reported and the long-term CV risk may be overestimated. chest pain in the year before the acute event. 257 019 patients had QRisk2 estimations. Chest pain was associated with a higher risk of CAD. HRs: 21.12 However, the recognition of CAD among (16.68 to 26.76), p<0.001; 7.51 (6.49 to 8.68), those who report chest pain remains dif fi cult p<0.001; and 1.84 (1.14 to 3.00), p<0.001 for in primary care as chest pain only represents specified, unspecified and musculoskeletal chest pain. CAD in 8% 2 to 11% 3 – 5 of the patients. The Dyspepsia, dyspnoea or fatigue was also associated guidelines of both the UK National Institute with a higher risk of CAD. Chest pain of all subtypes, for Health and Care Excellence (NICE) and dyspepsia and dyspnoea were also associated with an 1 Centre for Primary Care and the American Heart Association acknowledge increased 10-year cardiovascular risk of 20% or more. Public Health, Queen Mary that clinical assessment may be suf fi cient to Conclusions: All patients with chest pain, including University of London, con fi rm or exclude the diagnosis of CAD. 6 7 those with atypical symptoms, require careful London, UK The NICE guidelines recommend the estima- assessment for acute and longer term cardiovascular 2 Department of Non- risk. Prodromes may have independent diagnostic tion of risk of CAD based on the typicality of communicable Disease Epidemiology, London value in the estimation of cardiovascular disease risk. the pain, age, gender and cardiovascular School of Hygiene and (CV) risk factors, and suggest the consider- Tropical Medicine, London, ation of an alternative diagnosis if the esti- UK mated risk is below 10%. 6 Many patients 3 Department of Cardiology, referred to secondary care are now offered Barts Health NHS Trust, INTRODUCTION London, UK investigations which have high costs and Coronary artery disease (CAD) is the leading some involve exposure to ionising radi- cause of global mortality, accounting for 13% Correspondence to ation. 6 8 – 10 This care pathway emphasises the of deaths across the world. 1 Chest pain is a Dr John Robson; relevance of the initial clinical assessment in common presenting symptom of CAD. j.robson@qmul.ac.uk 1 Robson J, et al . BMJ Open 2015; 5 :e007251. doi:10.1136/bmjopen-2014-007251
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